Provider Demographics
NPI:1871622894
Name:KING, GLORIA RIVERA (PHD, MA)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:RIVERA
Last Name:KING
Suffix:
Gender:F
Credentials:PHD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 SILVER PALM AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3125
Mailing Address - Country:US
Mailing Address - Phone:321-506-8373
Mailing Address - Fax:321-956-1502
Practice Address - Street 1:109 SILVER PALM AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3125
Practice Address - Country:US
Practice Address - Phone:321-506-8373
Practice Address - Fax:321-956-1502
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5380101YM0800X
FLMT1771106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health